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DOI: 10.1055/s-0038-1641221
Behavioral Economics Interventions in Clinical Decision Support Systems
Publication History
Publication Date:
29 August 2018 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00034612/201801/lookinside/thumbnails/10-1055-s-0038-1641221_cho-1.jpg)
Summary
Background: Clinical decision support (CDS) systems can improve safety and facilitate evidence-based practice. However, clinical decisions are often affected by the cognitive biases and heuristics of clinicians, which is increasing the interest in behavioral and cognitive science approaches in the medical field.
Objectives: This review aimed to identify decision biases that lead clinicians to exhibit irrational behaviors or responses, and to show how behavioral economics can be applied to interventions in order to promote and reveal the contributions of CDS to improving health care quality.
Methods: We performed a systematic review of studies published in 2016 and 2017 and applied a snowball citationsearch method to identify topical publications related to studies forming part of the BEARI (Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections) multisite, cluster-randomized controlled trial performed in the United States.
Results: We found that 10 behavioral economics concepts with nine cognitive biases were addressed and investigated for clinician decision-making, and that the following five concepts, which were actively explored, had an impact in CDS applications: social norms, framing effect, status-quo bias, heuristics, and overconfidence bias.
Conclusions: Our review revealed that the use of behavioral economics techniques is increasing in areas such as antibiotics prescribing and preventive care, and that additional tests of the concepts and heuristics described would be useful in other areas of CDS. An improved understanding of the benefits and limitations of behavioral economics techniques is also still needed. Future studies should focus on successful design strategies and how to combine them with CDS functions for motivating clinicians.
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References
- 1 Thaler RH, Sunstein CR. Nudge: Improving decisions about health, wealth, and happiness. New Haven, CT: Yale University Press; 2008
- 2 Johnson EJ, Shu SB, Dellaert BG, Fox C, Goldstein DG, Häubl G. , et al. Beyond nudges: Tools of a choice architecture. Marketing Letters 2012; 23 (02) 487-504
- 3 Cialdini RB, Goldstein NJ. Social influence: Compliance and conformity. Annu Rev Psychol 2004; 55: 591-621
- 4 Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ, Griskevicius V. The constructive, destructive, and reconstructive power of social norms. Psychol Sci 2007; 18 (05) 429-34
- 5 Burchell K, Rettie R, Patel K. Marketing social norms: social marketing and the ‘social norm approach’. Journal of Consumer Behaviour 2013; 12 (01) 1-9
- 6 Ubel PA. What should I do, doc?: Some psychologic benefits of physician recommendations. Arch Intern Med 2002; 162 (09) 977-80
- 7 Blumenthal-Barby JS, Burroughs H. Seeking better health care outcomes: the ethics of using the “nudge”. Am J Bioeth 2012; 12 (02) 1-10
- 8 Purnell JQ, Thompson T, Kreuter MW, McBride TD. Behavioral Economics: “Nudging” Underserved Populations to Be Screened for Cancer. Prev Chronic Dis 2015; 12: E06
- 9 Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003; 78 (08) 775-80
- 10 Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002; 324 (7339): 729-32
- 11 Jaspers MW, Smeulers M, Vermeulen H, Peute LW. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc 2011; 18 (03) 327-34
- 12 Pearson SA, Moxey A, Robertson J, Hains I, Williamson M, Reeve J. , et al. Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990–2007). BMC Health Serv Res 2009; 9 (01) 154
- 13 Shortliffe EH, Cimino JJ. Biomedical informatics: computer applications in health care and biomedicine. Springer Science & Business Media; 2013
- 14 Greenes RA. Clinical decision support: the road ahead. Academic Press; 2011
- 15 Gong CL, Hay JW, Meeker D, Doctor JN. Prescriber preferences for behavioural economics interventions to improve treatment of acute respiratory infections: a discrete choice experiment. BMJ Open 2016; 6 (09) e012739
- 16 Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Making 2015; 35 (04) 539-57
- 17 Hallsworth M, Chadborn T, Sallis A, Sanders M, Berry D, Greaves F. , et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet 2016; 387 (10029): 1743-52
- 18 Ranji S, Steinman M, Shojania K, Sundaram V, Lewis R, Arnold S. , et al. Antibiotic prescribing behavior. Closing the quality gap: a critical analysis of quality improvement strategies. Technical Review 2006; 9: 255-61
- 19 Kahneman D. Thinking, fast and slow. Macmillan; 2011
- 20 Ariely D. Predictably irrational. New York: HarperCollins; 2008
- 21 Rooze S. , editor. Nudge: Improving Decisions about Health, Wealth and Happiness. Amsterdam: Law Forum; 2009
- 22 Hough DE. Irrationality in health care: what behavioral economics reveals about what we do and why. Stanford University Press; 2013
- 23 Platt ML, Huettel SA. Risky business: the neuroeconomics of decision making under uncertainty. Nat Neurosci 2008; 11 (04) 398
- 24 Lee D. Neuroeconomics: Best to go with what you know?. Nature 2006; 441 (7095): 822-3
- 25 Rice T. The behavioral economics of health and health care. Annu Rev Public Health 2013; 34: 431-47
- 26 Loewenstein G, Brennan T, Volpp KG. Asymmetric paternalism to improve health behaviors. JAMA 2007; 298 (20) 2415-7
- 27 Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas 1960; 20 (01) 37-46
- 28 Tannenbaum D, Doctor JN, Persell SD, Friedberg MW, Meeker D, Friesema EM. , et al. Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study. J Gen Intern Med 2015; 30 (03) 298-304
- 29 Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ. , et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016; 315 (06) 562-70
- 30 Persell SD, Friedberg MW, Meeker D, Linder JA, Fox CR, Goldstein NJ. , et al. Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01]-study protocol and baseline practice and provider characteristics. BMC Infect Dis 2013; 13 (01) 290
- 31 McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012; 22 (03) 276-82
- 32 Jensen-Doss A, Haimes EMB, Smith AM, Lyon AR, Lewis CC, Stanick CF. , et al. Monitoring treatment progress and providing feedback is viewed favorably but rarely used in practice. Adm Policy Ment Hlth 2018; 45 (01) 48-61
- 33 Chauhan BF, Jeyaraman M, Mann AS, Lys J, Skidmore B, Sibley KM. , et al. Behavior change interventions and policies influencing primary healthcare professionals’ practice-an overview of reviews. Implement Sci 2017; Jan 5; 12 (01) 3
- 34 Rudolf JW, Dighe AS, Coley CM, Kamis IK, Wertheim BM, Wright DE. , et al. Analysis of Daily Laboratory Orders at a Large Urban Academic Center A Multifaceted Approach to Changing Test Ordering Patterns. Am J Clin Pathol 2017; Aug; 148 (02) 128-135
- 35 Sheridan SL, Sutkowi-Hemstreet A, Barclay C, Brewer NT, Dolor RJ, Gizlice Z. , et al. A Comparative Effectiveness Trial of Alternate Formats for Presenting Benefits and Harms Information for Low-Value Screening Services A Randomized Clinical Trial. JAMA Intern Med 2016; Jan; 176 (01) 31-40
- 36 Gimbel RW, Pirrallo RG, Lowe SC, Wright DW, Zhang L, Woo MJ. , et al. Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial. BMC Med Inform Decis Mak 2018; 18 (01) 20
- 37 Mohan D, Farris C, Fischhoff B, Rosengart MR, Angus DC, Yealy DM. , et al. Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial. BMJ 2017; Dec 13: 359
- 38 Mohan D, Rosengart MR, Fischhoff B, Angus DC, Farris C, Yealy DM. , et al. Testing a videogame intervention to recalibrate physician heuristics in trauma triage: study protocol for a randomized controlled trial. BMC Emerg Med 2016; Nov 11; 16 (01) 44
- 39 Saver BG, Mazor KM, Luckmann R, Cutrona SL, Hayes M, Gorodetsky T. , et al. Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions. Ann Fam Med 2017; Jan; 15 (01) 48-55
- 40 Schwartz PH, Perkins SM, Schmidt KK, Muriello PF, Althouse S, Rawl SM. Providing Quantitative Information and a Nudge to Undergo Stool Testing in a Colorectal Cancer Screening Decision Aid: A Randomized Clinical Trial. Med Decis Making 2017; Aug; 37 (06) 688-702
- 41 Schnaus MJ, Michalik M, Skarda P. Effects of Electronic Medical Record Display on Provider Ordering Behavior: Leveraging the EMR to Improve Quality and Costs. Am J Med 2017; Dec; 130 (12) 1366-71
- 42 Saposnik G, Maurino J, Sempere AP, Ruff CC, Tobler PN. Herding: a new phenomenon affecting medical decision-making in multiple sclerosis care? Lessons learned from DIScUTIR MS. Patient Prefer Adher 2017; 11: 175-80
- 43 Saposnik G, Sempere AP, Raptis R, Prefasi D, Selchen D, Maurino J. Decision making under uncertainty, therapeutic inertia, and physicians’ risk preferences in the management of multiple sclerosis (DIScUTIR MS). BMC Neurol 2016; May 4; 16
- 44 Sedikides C, Herbst KC, Hardin DP, Dardis GJ. Accountability as a deterrent to self-enhancement: The search for mechanisms. J Pers Soc Psychol 2002; 83 (03) 592-605
- 45 Lerner JS, Tetlock PE. Accounting for the effects of accountability. Psychol Bull 1999; 125 (02) 255-75
- 46 Goldstein NJ, Cialdini RB, Griskevicius V. A room with a viewpoint: Using social norms to motivate environmental conservation in hotels. J Consum Res 2008; 35 (03) 472-82
- 47 Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981; 211 (4481): 453-8
- 48 Samuelson W, Zeckhauser R. Status quo bias in decision making. J Risk Uncertainty 1988; 1 (01) 7-59
- 49 Glimcher PW, Camerer CF, Fehr E, Poldrack RA. Neuroeconomics: Decision Making and the Brain. Elsevier; 2009
- 50 Levy I, Snell J, Nelson AJ, Rustichini A, Glimcher PW. Neural representation of subjective value under risk and ambiguity. J Neurophysiol 2009; 103 (02) 1036-47
- 51 Anderson LR, Mellor JM. Predicting health behaviors with an experimental measure of risk preference. J Health Econ 2008; 27 (05) 1260-74
- 52 Sethi-Iyengar S, Huberman G, Jiang W. How much choice is too much? Contributions to 401 (k) retirement plans. In: Mitchell OS, Utkus SP. Pension design and structure: New lessons from behavioral finance. 2004. . p. 84–7
- 53 Opel DJ, Omer SB. Measles, mandates, and making vaccination the default option. JAMA Pediatr 2015; 169 (04) 303-4
- 54 Dayan E, Bar-Hillel M. Nudge to nobesity II: Menu positions influence food orders. Judgm Decis Mak 2011; 6 (04) 333-42
- 55 Kjær T, Bech M, Gyrd Hansen D, Hart Hansen K. Ordering effect and price sensitivity in discrete choice experiments: need we worry?. Health Econ 2006; 15 (11) 1217-28
- 56 White JS, Dow WH. Intertemporal choices for health. Behavioral Economics and Public Health; 2015. p. 62
- 57 Heath C, Heath D. Chapter 8: Tweak the Environment. Switch: How to Change Things When Change is Hard. New York, N.Y.: Broadway Books; 2010
- 58 Taylor SE, Fiske ST. Salience, Attention, and Attribution: Top of the Head Phenomena. Advances in Experimental Social Psychology. Elsevier; 1978: 249-288
- 59 Stryker S, Serpe RT. Identity salience and psychological centrality: Equivalent, overlapping, or complementary concepts?. Soc Psychol Q 1994; 16-35
- 60 Norton MI, Mochon D, Ariely D, The IK. EA effect: When labor leads to love. J Consum Psychol 2012; 22 (03) 453-60
- 61 Easley D, Kleinberg J. Chapter 16: Information Cascades. Networks, Crowds, and Markets: Reasoning about a Highly Connected World. Cambridge: Cambridge University Press; 2010: 483-508
- 62 Bornstein BH, Emler AC. Rationality in medical decision making: a review of the literature on doctors’ decision making biases. J Eval Clin Pract 2001; 7 (02) 97-107
- 63 Davis DA, Mazmanian PE, Fordis M, Van Harrison RR, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. JAMA 2006; 296 (09) 1094-102
- 64 Croskerry P. From mindless to mindful practice cognitive bias and clinical decision making. N Engl J Med 2013; 368 (26) 2445-8
- 65 Spranca M, Minsk E, Baron J. Omission and commission in judgment and choice. J Exp Soc Psychol 1991; 27 (01) 76-105
- 66 Kiefe CI, Allison JJ, Williams OD, Person SD, Weaver MT, Weissman NW. Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial. JAMA 2001; 285 (22) 2871-9
- 67 O’Connor SD, Sodickson AD, Ip IK, Raja AS, Healey MJ, Schneider LI. , et al. Journal club: Requiring clinical justification to override repeat imaging decision support: impact on CT use. AJR Am J Roentgenol 2014; 203 (05) W482-W490
- 68 Armstrong K, Schwartz JS, Fitzgerald G, Putt M, Ubel PA. Effect of framing as gain versus loss on understanding and hypothetical treatment choices: survival and mortality curves. Med Decis Making 2002; 22 (01) 76-83
- 69 Thaler RH, Benartzi S. Save more tomorrow.: Using behavioral economics to increase employee saving. J Polit Econ 2004; 112 (S1): S164-S187
- 70 Johnson EJ, Goldstein D. Do defaults save lives?. Science 2003; 302 (5649): 1338-9
- 71 Bourdeaux CP, Thomas MJ, Gould TH, Malhotra G, Jarvstad A, Jones T. , et al. Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses. BMJ Open 2016; 6 (05) e010129
- 72 Schuler CL, Courter JD, Conneely SE, Frost MA, Sherenian MG, Shah SS. , et al. Decreasing duration of antibiotic prescribing for uncomplicated skin and soft tissue infections. Pediatrics 2016; 137 (02) e20151223
- 73 Gordon MK, Baum RA, Gardner W, Kelleher KJ, Langberg JM, Brinkman WB. , et al. Comparison of performance on ADHD quality of care indicators: practitioner self-report versus chart review. J Atten Disord 2016; 1087054715624227
- 74 Rickert D, Santoli J, Shefer A, Myrick A, Yusuf H. Influenza vaccination of high-risk children: what the providers say. Am J Prev Med 2006; 30 (02) 111-8
- 75 Alexander GC, Humensky J, Guerrero C, Park H, Loewenstein G. Brief report: Physician narcissism, ego threats, and confidence in the face of uncertainty. J Appl Soc Psychol 2010; 40 (04) 947-55
- 76 Forrest CB, Fiks AG, Bailey LC, Localio R, Grundmeier RW, Richards T. , et al. Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics 2013; 131 (04) e1071-81
- 77 Gerber JS, Prasad PA, Fiks AG, Localio AR, Grundmeier RW, Bell LM. , et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013; 309 (22) 2345-52
- 78 Hernandez M. Toward an understanding of the psychology of stewardship. Acad Manage Rev 2012; 37 (02) 172-93
- 79 Hall AB, Montero J, Cobian J, Regan T. The effects of an electronic order set on vancomycin dosing in the ED. Am J Emerg Med 2015; 33 (01) 92-4
- 80 Nanji KC, Slight SP, Seger DL, Cho I, Fiskio JM, Redden LM. , et al. Overrides of medication-related clinical decision support alerts in outpatients. J Am Med Inform Assoc 2014; 21 (03) 487-91
- 81 Schreiber R, Gregoire JA, Shaha JE, Shaha SH. Think time: A novel approach to analysis of clinicians’ behavior after reduction of drug-drug interaction alerts. Int J Med Inform 2017; 97: 59-67
- 82 Cho I, Lee Y, Lee JH, Bates DW. Wide Variation and Patterns of Physicians’ Responses to Drug- Drug Interaction Alerts. . Int J Qual Health Care 2018 May 8
- 83 Ubel P. Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. 1st ed. New York: HarperOne; 2012
- 84 DellaVigna S. Psychology and economics: Evidence from the field. J Econ Lit 2009; 47 (02) 315-72
- 85 Berner ES. Clinical decision support systems. Springer; 2007